55year old female with dengue and meningoencephalitis.

SHORT CASE - FINAL MBBS PART 2 PRACTICAL EXAMINATION.

Name : M VARUN SAI

REG. NO.: 1701006099

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CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

CASE REPORT ::

A 55year old female patient who is housewife hailing from nalgonda was brought to the hospital with 

CHIEF COMPLIANTS ::

* Fever since 5 days .

* Neck stiffness since 5 days.

HISTORY OF PRESENT ILLNESS ::

Patient was apparently asymptomatic 5 days back and was able to perform her regular activities without any difficulty then she experienced 

FEVER 

             sudden onset 

             Continuous 

             Associated with chills and rigor 

             Associated with generalised body pains and headache .

             Associated with 1 episode of vomiting which is non projectile, non bilious , food particles as content and non foul smelling. Not associated with abdominal pain and loose stools.

             Relieved on medication.

NECK STIFFNESS 

             Sudden onset

              Associated with decreased range of movements at neck 

              No H/O trauma

              Not relieved on rest and painkillers.

 

No H/O Burning micturition.

PAST HISTORY ::

No similar compliants in the past.

Not a known case of hypertension , Tuberculosis,  epilepsy, asthma and CAD.

H/O CVA   with compliants of bilateral upper & lower limb paralysis 7 years back for which she was treated and recovered in 1month .

Surgical H/O - Hysterectomy 25years back.

PERSONAL HISTORY ::

Diet - Mixed 

Appetite - reduced 

Sleep - adequate 

 bladder - regular 

Bowel movements - constipation since 3 days

No addictions and no known allergies.

FAMILY HISTORY ::

Not significant.

GENERAL EXAMINATION ::

Patient is conscious, coherent, and cooperative.

Moderately built and nourished.

Well oriented to time, place and person.

Patient was examined in supine position in a well lighted room after taking consent and explaining the procedure.

PALLOR - absent 

ICTERUS - absent

CLUBBING - absent

CYANOSIS - absent 

LYMPHADENOPATHY - absent 

EDEMA - absent

VITALS ::

Temperature - 99⁰F 

Pulse rate - 98 beats per minute , normal                       volume , character and                                  normal vessel wall , no                                radioradial and radiofemoral

                      delay .

Respiratory rate - 20cycles per minute

Blood pressure - 110/70 mmHg in both                                  arms.

O2 sat. - 96% at room air.

SYSTEMIC EXAMINATION::

CNS EXAMINATION:

Higher mental functions : NORMAL

Cranial nerve examination :

            All cranial nerves functions are intact.

Cerebellar examination : No abnormality detected 

Sensory system examination - Normal .

Motor system - 

     Muscle bulk - normal in both upper and lower limbs.

     Tone - normal in both upper and lower limbs. 

      Power - normal in both upper and lower limbs.

nuchal muscle stiffness present , slight tenderness over the neck.

     Reflexes - 

            Biceps - present on both sides

            Triceps - present on both sides

            Supinator - present

            Knee - present on both sides

            Ankle - present on both sides

            Plantar reflex - normal bilaterally.

Meningeal signs:

neck stifness - present

Kerning's sign - positive

Brudzinski's sign - positive .

Other system examination :

 Cardiovascular system - 

              S1 , S2 heard , no murmurs.

Respiratory system examination -

              Bilateral air entry present

              Normal vesicular breath sounds

              No advetitious sounds.

Per abdomen examination -

             Soft and non tender 

             No organomegaly .

DIAGNOSIS:

 ? Viral infection with 2⁰ viral meningoencephalitis under evaluation.

 

INVESTIGATIONS ::

 HEMOGRAM ::

LIVER FUNCTION TEST:

RENAL FUNCTION TEST:

ARTERIAL BLOOD GAS ANALYSIS:

COMPLETE URINE EXAMINATION:

ECG :

MRI of BRAIN:

Findings : few areas of leptomeningeal enhancement in the sulcal areas of parietal and occipital region.

X RAY - SKULL& CERVICAL SPINE :   

PROVISIONAL DIAGNOSIS :

Dengue fever with meningoencephalitis.

Denovo type 2 Diabetes mellitus.

TREATMENT ::

Inj. CEFTRIAXONE 2 gm/ BD 

Inj.DEXAMETHASONE 6mg/iv/tid

Inj . Vancomycin 1gm/iv

Inj. Paracetomol 1gm/iv

Tab . Paracetomol 650 mg 

Tab. Ecospirin 75 mg /po/od

Tab. Atorvastatin 10 mg /po/od

Syp. Cremaffin plus 30ml/po .